12070155CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 23500 CRISTO REY DR UNIT 310 C-
CON'RAC'MR: BAY AREA
PERMIT No: 12070155
ENTERPRISE
OWNER'SNAME: LILLIAN TSUI
2110MANGIN WAY
DATE ISSUED: 07/19/2012
OWNIiH'S PHONE:
SAN JOSE, CA 95148
PHONE NO: (408)238-5043
❑` LICENSED COi\ fRAC`fOR'S DECLARATION
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BUILDING
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Class 16 Lic. # T3/ � / ,S ///
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Contactor '1 �Y4 1IbatcZ4��%/
?IFCII RFSIDhL\'1'IdL COMMERCIAL
3013 DESCRIPTION: INSTALL NEW SHOWER STALL AND OUTLET
1 hereby' affirm that 1 ant icensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business \ Professions
Code and that my license is in full force and effect.
1 hereby affirm under penally of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued
Sq. FI Floor Area:
Valuation: $750
1 haveand will maintain Worker's Compensation Insurance, as provided for by
\I'N Number: 34253114.00
Occupancy Type:
Section 3700 of the Labor Code, for the performance of Ore work for which this
permit is issued.
APPLICANT CBRTI FICATION
I certify that l have read this application and store that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. l agree to comply with all city and county ordinances and state laws relating
WITHIN180 DAPS OF PERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
180 DAN' F OM LAST CALLED INSPECT ON.
indemnify and keep harmless the Cily of Cupertino against liabilities, judgments.
costs, and expenses wi ch may ace c against said City in consequence of the
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Date:
granting of this perm Addition y, the applic:at understands and will comply
Issued by: i
with all non -point t cc regulatio s per the Cupertino Municipal Cade, Section
RE -HOOFS:
9.18.
Signature 'Date
All roofs shall be inspected prior to any roofing material being installed. I(a roof is
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installed without first obtaining an inspection,.I ac_ree to remove all new materials for
inspection.
❑ OWNER-11MIME,R DECLARA'T'ION
Signature of Applicants Date:
1 hereby affirm than I am exempt from the Contractor's License Law for one of
the following two reasons:
AL1- ROOF COVE) RINGS TO BE CLASS "A" Olt IiETFER
1, as owner of the property, or my employees with wages as their sole compensation.
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business R Professions Code)
L as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS 1)ISCLOS 1112E
construct the project (Sec.7044, Business R Professions Code).
I have read the hazardous materials requirements under Chapler 6.95 of the
California Ilcallh A Safely Code. Sections 2.5505, 25533, and 25534, 1 will
1 hereby affirin under penalty of perjury nor of the following three
maintain compliance with the Cupertino Municipal Code. Chapter 9.12 and the
declarations:
Health S Safety Code, Section 25532(a) should I store or handle hazardous
I have and will maintain a Cenificalc of Consent to self -insure for Worker's
material. Additionally, should I use equipmentor criers ahich emit h�izardous
Compensation, as provided for by Section 3700 of the labor Code, for the
air cunlantinanls as defined to, the Bay Area Air uglily dlanagemeni District 1
performance of the work for which this permit is issued.
will maintain compliance with the Cu pert, o M licipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
the Ilealth S Safety Code, Sections'_.5 51 ,. nd 25531.
- Dore:
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Ownerr authorized agent:
permit is issued.
I certify that in the performance of the work for which this permit is issued I shall
not employ any person in any manner so as to become subject to the Worker's
CONS'1'ItUCFICha LENDING ACP:�'C1'
Compensation laws of Callfernia. If, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, I hast
I hereby aff r n that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state Imus relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
ABC1ll'FECI"S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities. Judgments,
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date
CUPERTINO
❑ NRV [ONSTRrtrTlnw
CONSTRUCTION PERMIT APPLICATION
COMMIiNP� DEV- .;• MSN: DEPARTMENT - gUILWG DN?SiON \t>�
10300 TORRE AVENUE . CUPERTINO, CA 95714-3255 0
(408) m-3228 • FAX (408) 777-3333 • huidirnr. a
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SUPPL24ENTALWOR-MATIONREQLTMP — �,� ��� j
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_ New SFD or MUitifarrily dwellings: Apply for demolition permit for r1
y Ov�.T ou,hTEa ❑
existing building(s)- Demolition permit is reCmIed prior to issuance OI building BL-QaNG PIAY BEVOi W
PM= for new banding. ❑-� EXPRESS ❑
PLATR-C7G PLIY REVIEW
_ CO�erfal Bldg:HazardousOS•D
de a c=Dlemd Hazardous �•I61PS:a13 Discle ❑ STANDARD 0
rum rc WORES
fbrm If my Hazardous Materials are- being used as part of this project
❑ LARGE ❑ FtaB DEPT
_ Copy of Planning Approval Letter or katcag w;rh PfaDvmg pr:Dr to
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SUb ruttal of Building Permit Epplitatico- oR G SAhTrARY SewER DLstarcr
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